SELF EVALUATION
RADIATION THERAPY SKILLS PROFICIENCY CHECKLIST

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If you prefer, you can print a form to fax or mail.
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     Last Name: 
    First Name: 
Middle Initial: 
Years Experience: yrs.

DIRECTIONS: Place an x in the box that best describes your level of proficiency for each of the skills presented.

LEVELS OF PROFICIENCY KEY:

HP =

Highly Proficient.
Extensively experienced; able to supervise and/or train others.

 SE =

Some Experience.
Need review and assistance or supervision.
VE =

Very Experienced.
Can perform well without assistance or supervision.

 NE = No Experience.
EX =

Experienced.
Competent; can perform independently; may need initial review or supervision.
TREATMENT SETUPS: HP VE EX SE NE
Tangent Chestwall
Tangent Breast
      1) SSD/SAD – 2 Fields
      2) SSD/SAD – 3 Fields
      3) +AP Supraclav+PAB
2 Field Pelvis/Prostate
4 Field Pelvis/Prostate
7 Field Pelvis/Prostate
ARC/Rotational Pelvis/Prostate
2 Field Lung
Oblique/Off Cord Lung
Full Mantle
3 Field Head and Neck
Whole Brain/Hand-Eye Block
Whole Brain/German Helmet
Inverted Y Field
Hockeystick Field
Penis/Scrotum/Testes w/Shields
Pituitary Gland
Whole Body Irradiation
Mycosis Fungoides
Larynx
Moving Field/Whole CNS
Mixed Beam - Photon/Electron Match
Prone Colorectal
Prone Esophagus
Orbit with Hanging Block
Superior Vena Cava
Spinal Cord Compression
C-Spine with Patient in Halo
Other Specialty Set-ups:
TREATMENT ACCELERATORS: HP VE EX SE NE
Varian 4-100
Varian 6-100
Varian D.E. 6/18
Varian 2100 C
Varian 2100 CD MLC
Siemens D.E. 6/15
Siemens D.E. 6/18
Philips Units
General Electric Units
Other:
SIMULATORS: HP VE EX SE NE
Kermath
Ximatron
Toshiba
Philips
Varian 2100
Oldelft
AECL
Cascade
Other:
Other:
Other:
SUPERFICIAL UNITS: HP VE EX SE NE
General Electric
Other:
H.D.R. UNITS: HP VE EX SE NE
Nucletron
Other:
FILM PROCESSORS: HP VE EX SE NE
Kodak
Other:
FABRICATION OF IMMOBILIZATION DEVICES: HP VE EX SE NE
Cerrobend Blocks
Electron Blocks
Alpha Cradles
Aqua Plast Masks
Brass Step Compensators
Custom Wax Forms
Vacuum Formed Masks
Intraoral Biteblocks
Vacuum Cradles
Plaster Strip Masks
MISC. EQUIPMENT: HP VE EX SE NE
Cobalt-60 Units-Theratron
Hyperthermia Units
Any Accelerators w/Beamstopper
Other:
RECORD & VERIFY SYSTEMS: HP VE EX SE NE
Varis–Varian
Lantis–Siemens
Impac–Siemens
Philips–Philips
MISC. SKILLS: HP VE EX SE NE
Photon Hand Calculations
Electron Hand Calculations
Standard Portal Films
Orthogonial Protal Films
Patient Tatooing
Morning Treatment Unit Warmup
Morning Simulator Warmup
Quality Assurance
     Accelerator Checks
Accelerator Output Checks
Other: 
Submitted by:      Date:

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